Membership

Name (required)

Address (required)

Please check the appropriate box (required).
Are you: a person with aphasiaa caregivera friend of a person with aphasia

The following questions relate to people with aphasia only:

Do you have any medical conditions, e.g. heart problems, epilepsy, hearing loss, etc or special
Yes/No
If yes, please
describe

Date(s) of your
stroke(s)

If your aphasia is not a result of a stroke, please indicate cause of the aphasia:

Please try to tell us about your aphasia:

Your ability to express yourself verbally:

Your understanding of what others are saying:

Your understanding of what you read:

Your ability to express yourself in writing: